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Art Therapy – A Review of Methodology
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ISSN 2076-7099
Психологический журнал
Международного университета природы, общества и человека «Дубна» № 4, с. 29-43, 2015
Dubna Psychological Journal www.psyanima.ru
Art Therapy – A Review of Methodology
Minh-Anh Nguyen
Officially founded as an independent science in the United States in the late sixties, Art therapy,
although still borrows the theoretical fundament of psychoanalysis, has its own distinctive
characteristics. This paper attempts to review the methodology of art therapy. When not aiming at the
overview of art therapy history, it presents art therapy’s most pivotal features, including its difference
from art education, non-verbal communication, metaphoric meaning and relationship-oriented
character. The levels of Expressive Therapies Continuum (ETC) as developmental steps and the use of
art therapy media are also presented in this paper.
Keywords: art therapy, art education, symbolism, non-verbal communication, metaphor,

Expressive Therapies Continuum (ETC), art therapy media
“Emotion, which is suffering, ceases to be

suffering as soon as we form a clear and precise
picture of it”
Frankl, V.E. (1959). Man’s Search for
Meaning. New York: Pocket Books, p. 117.
1. Definition of Art therapy
1.1. Art therapy

Art therapy is based on the idea that the creative process of art making is healing and
life enhancing and is a form of nonverbal communication of thoughts and feelings (American
Art Therapy Association, 1996, in Malchiodi, 2003, p. 1). Art therapy is based upon the
theory that early trauma or developmental conflict may not be accessible through typical
verbal language but rather is stored in the unconscious in pre-verbal forms of sensory,
kinesthetic or imaginal cognitions and associated emotional experiences represented in
symbolic language (Robbins, 2000; Wadeson, 2010). The process of accessing these pre-
verbal ways of knowing and experiencing requires the development of an intentional
therapeutic relationship or holding environment in which the therapist attunes to, joins with
and mirrors the pre-verbal consciousness of the client. Using emotional presence and
attunement the art therapist selects relevant art processes to mirror the clients emotional and
relational state and consequently nurture the emergence of metaphoric and symbolic language
that re-constructs the personal narrative of the client (Gerber, 2014; Robbins, 2000). Outcome
studies showed that long-term individual art therapy was effective in promoting cognitive and
emotional development, enabling relationships and lessening destructive behaviors in adults
and children (Alders & Levine-Madori, 2010, Dudley, 2004; Evans & Dubowski, 2001;
Henley, 2001; Klorer, 2000, 2005; Klorer & Robb, 2012; Kornreich & Schimmel, 1991;
Kramer, 1977; McGregor, 1990; Ponteri, 2001; Smitheman-Brown & Church, 1996; Spring,
2001; Tipple, 2003).
The first master's degree in art therapy in the USA was offered at Hahnemann Hospital
and Medical College (now Drexel University) in Philadelphia in 1967 (Westwood, 2010).
Until that point art therapy was taught in New York City by Margaret Naumburg, and in
Washington, D.C. at the Washington School of Psychiatry. Art therapy was finally able to
stand as a legitimate discipline incorporating elements of both art and therapy in 1970 when
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Психологический журнал Minh-Anh Nguyen
the American Art Therapy Association held its first annual conference (The First AATA
Conference Program, 1994).
1.2. Art therapy vs. Art education

According to Rubin (1978), “Perhaps one of the ways in which art therapy differs
from art in other contexts is the importance of the relationship between the therapist and
client(s). For creating art within a therapeutic relationship is different from drawing by
oneself or working in a class. It is a kind of special protected situation, where one person
creates an environment, physical and psychological, in which one or more others can fully
explore, expand, and understand themselves through art. In this relationship, the child
voluntarily exposes himself to another, and learns to look with that other person at his creative
statements and at himself. Often there are few or no words, yet the being together and sharing
of both process and product offer protection, validity, even permanence, to the event, which
could otherwise be so vulnerable, so fragile (Rubin, 1978, p. 270).
Malchiodi (1998) mentioned: “Art therapy supports the belief that all individuals have
the capacity to express themselves creatively and that the product is less important than the
therapeutic process involved. The therapist’s focus is not specifically on the aesthetic merits
of art making but on the therapeutic needs of the person to express. That is, what is important
is the person’s involvement in the work, choosing and facilitating art activities that are helpful
to the person, helping the person to find meaning in the creative process, and facilitating the
sharing of the experience of image making with the therapist” (p. 1). This viewpoint
dramatically distinguishes art therapy from art education and activities per se. Besides that, art
therapy has been influenced by psychological theories including psychodynamic,
developmental, humanistic and cognitive behavioral and therefore various approaches have
been developed. These theoretical approaches and therapeutic aspects have brought art
therapy specific characteristics that are not included in art education or art activities
themselves.
2. Two leading models of Art therapy
2.1. Art in therapy of Margaret Naumburg

The integration of Freudian thinking about the dynamics of unconscious
communication with its facilitation through the images and symbols of art was primarily
initiated by Margaret Naumburg. In the Walden School founded in 1915 by herself (1928),
Naumburg recommended that all her teachers undertake analysis and she encouraged the
children in "spontaneous, free art expression" which produced "original and amazing images"
seemingly "created from their unconscious". This lead to Naumburg's (1928) conviction that,
"such free art expression in children was a symbolic form of speech basic to all education...
that such spontaneous art expression was also basic to psychotherapeutic treatment" (p. 30).
Naumburg (1958), actually referred to as the founder of art therapy, based her “art
psychotherapy” theoretical framework and its methods on releasing spontaneous art
expression; it has its roots in the transference relation between patient and therapist, and on
the encouragement of free association. Naumburg used art as the means for clients to visually
project their conflicts. For Naumburg (1958), the value of therapeutic art, "is based on the
recognition that man's most fundamental thoughts and feelings, derived from the unconscious,
reach expression in images rather than words" (p. 511). But while taking the technique of free
association from psychoanalysis, Naumburg did not agree with the Freudian’s stress on
putting subjective experiences into words. In contrasting the two approaches Naumburg stated
that “In art therapy the patient’s unconscious imaged experience is transposed directly into an
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actual pictured image” whereas in psychoanalysis “such inner visual experiences must be
retranslated from an imaged into a verbal communication” (Naumburg, 1966, p. 2).
Naumburg proposed once patient had created nonverbal spontaneous imagery they
would make verbal associations to their pictures. She also believed that art therapy, like
psychotherapy, takes place within a transference relationship, but she departed from
traditional analytic techniques in that she insisted that the patient sit upright, take an active
rather than dependent role, and analyze and interpret his or her own imagery (Junge & Asawa,
1994, p. 24-25). Margaret Naumburg’s formulation clearly focused on the therapy part rather
than the art aspect. And as we see, Naumburg emphasized the interpretation of the client’s
artwork.
2.2. Art as therapy of Edith Kramer

Edith Kramer developed the term “art as therapy” (Ulman in Rubin, 1987, p. 281). Her
premise was that the art process itself allowed the client to recreate primary experiences and
feelings, thereby offering the opportunity to “re-experience, resolve and integrate conflict”
(Ulman in Rubin, 1987, p. 280).
Kramer’s theoretical model focused on art as therapy, rather than in therapy as
Naumburg suggested (Junge & Asawa, 1994, p. 31). Although Kramer used psychoanalytic
theory to form her approach to art therapy, she separated the role of the art therapist from that
of the psychotherapist in no uncertain terms. Viewing her work as a rather special form of art
class, she called her clients “students” and stated that the art therapist must be skilled as artist,
teacher, and therapist: “The art therapist… communicates with his students via the students’
paintings and this communication has therapeutic value… But he is no psychotherapist, and it
is not his function to interpret deep unconscious content to his students… The basic aim of the
art therapist is to make available to disturbed persons the pleasures and satisfaction which
creative work can give.” (Kramer, 1958, p. 5). Kramer cautioned that the art therapist “will
not, as a rule, directly interpret unconscious meaning, but… will use his knowledge to help
the child produce art work that contains and expresses emotionally loaded material” (Kramer,
1971, p. 34). Not advocating the uncovering of conflicts or the attacking of defenses,
Kramer’s primary focus is on the use of art to enhance sublimation, the process that was
defined by Freud as a defense mechanism of the ego in which primitive asocial influence is
transformed into a socially productive act (Junge & Asawa, 1994, p. 34-35). Kramer
emphasized the art process itself.
3. Characteristics of Art therapy
3.1. Non-verbal communication

Nonverbal communication is our most basic form of communication and it is how
caregiver and infant initially connect in the first years of life (Schore, 2003). Since thoughts
and feelings are not strictly verbal and are not limited to storage as verbal language in the
brain, art therapy is particularly useful in helping individuals communicate their stories that
may not be readily available through words. For some individuals, conveying a memory or
story through artistic modality is more easily tolerated than verbalization.
According to Dewey (1934), “If all meanings could be adequately expressed by
words, the arts of painting and music would not exist” (p. 74). When it comes to emotions, art
forms transfer our internal messages more authentically, yet diversely, than verbal means.
Noted art philosopher, Langer (1942), calls the internal world feeling and argues that the form
of art is designed to convey this feeling to others. According to Langer (1942, 1953), art’s
form is comprised of the visual, structural elements of the artwork such as color, line,
composition, etc. Langer believes that artistic form may be used to represent internal feeling
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in a structural way. Form is the structure of the art, and it is this structure to which we respond
when we view, hear, or otherwise experience it.
Art therapy and other healing practices incorporating creative expression become very
useful, particularly in settings where talking or writing is not possible, or conducive to
healing. A young child or disabled person may not be able to speak or have adequate
vocabulary. A victim of a crime may find security using creative expression as a tool to
protect oneself (Glazer, 1998; Henderson, 2007; Rogers 1993). A perpetrator of a crime may
find solace in using creative expression as a tool for healing, displacing or avoiding shame
and guilt. When working with clients, the process of creative expression allows one “to enter
into an organic, spontaneous process that comes from a deep and usually non-verbal place”
allowing “the client and therapist to hear and respond to the voice of the soul”, as Rowe
references Signell, 1996 (Rowe, 2008, p. 121). Non-verbal expression through a painting may
be, in and of itself, a corrective experience.
3.2. Metaphor as therapeutic means

“Feeling without symbolization is blind; symbolization without feeling is empty”
(Gendlin, 1962, p. 5).
Moon (2007) says that “all artworks are metaphoric depictions of the people who
create them” (p. 3). Metaphoric imagery can provide clients and therapists psychological
insights that go beyond linear rationality. “In response to clients’ metaphors, I often create
stories or poems about the images, and encourage clients to do the same” (Moon, 2007, p. 4).
Artwork allows the client to express symbolism, metaphor and feeling with much of
the freedom of dreams. Simultaneously with art, the person moves in and out of the repertoire
of practical and psychological skills, which are part of being an aware growing person. Keyes
(1983) finds that “… Using art materials to make images and connecting them to feelings and
body states brings into the open emotions and thoughts that have been only vaguely sensed.
Closure becomes possible for unfinished issues that push for resolution” (p. 104).
The concepts of signs and symbols are explored by theorists in a wide variety of
disciplines. Humans use a system of signs to communicate about both concrete and abstract
concepts. A sign is generally considered to be a stand-in; one says “cow,” for instance, rather
than going to the field, tying a rope around a cow’s neck, and leading it into the room. A
symbol represents something deeper – the experience of larger and more complex concepts,
which are harder to reduce to signs.
In general, psychological theorists tend to be more interested in symbols (meanings)
than signs (names). What Freud (1965) called symbols are actually closer to signs; they serve
as stand-ins (e.g. the famed cigar). Jung’s (1933) symbols represent a deeper, ineffable,
mystical process in which the psyche works to heal and defend itself. Lacan (2002) and
Kristeva (as described in Borch-Jacobsen, 1991; Bowie, 1993) also wrote extensively about
symbols, in particular their semiotic meaning and the interplay between internal signs and
external symbols.
Speech does not seem to be a natural mode for communicating connotation. Where
verbal and visual signs fall short, art can function as a symbol and, as Langer (1942, 1953)
and others (Borch-Jacobsen, 1991; Bowie, 1993) would argue, may do so in a way that is
more powerful and more effective than verbal signs alone.
Metaphor means “to carry across” in Greek. Without metaphor, language conveys
isolated undimensional experiences. With metaphor, language is a tool that allows us to
model a universe of infinite possibility. As it shatters old paradigms, metaphor releases new
energies and stimulates new experiences. In placing a “radiant obstacle in the path of the
obvious” (Cox & Theilgaard, p. 139 in Gorelick, 1989) metaphor can change the perception
of events and interpretation of experience. In sum, metaphors convey and link the basic
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elements of our nature, including the unconscious, defenses, relationships, the reframing of
old experiences and learning of new ways, self-actualization, and transcendence (Gorelick,
1989). Metaphor is the “common carrier” that ensures that each school of psychotherapy is
represented in all others, and all in each. The CATs have the distinction that our central
concern is the creation and application of metaphor itself. Tolaas (1991) proved that metaphor
has physical and social nature and is conceptualized during the first year of life.
For Moon (2007), “visual metaphors foster opportunities to support, inform, engage,
offer interpretations, provoke thought, and gently confront clients in ways that are potentially
safe and psychologically non-threatening” (p. 15). Artistic metaphors are indirect expressions
and, therefore, less confrontational and psychologically threatening than direct statements. An
artwork is an externalized object once removed the client. Consider the difference between
asking a client to “explain why you are defensive” and asking the same client to “draw walls.”
The content of the client’s expressions might be similar in both instances, but the affective
experience could be markedly different. The act of drawing a wall can be a safer, less anxiety-
provoking way to deal with personal defenses. This quality of safety depends upon both the
art therapist’s ability to keep within the structure of the metaphor and the client’s capacity to
trust the art-making process. Artistic metaphors also provide opportunities for clients to
reframe their experiences by looking at situations from new perspectives and making them
concrete in visual images. Beside that, when an art therapist creates art alongside the client,
the act of working together encourages a relationship that goes deeper than words.
As metaphor is one of the most common literary devices, it can be found in almost any
text. Some metaphors found in The Bible are alluded to and referenced in many other texts, so
it pays to be familiar with them and understand what is being said. For example, “I am the
vine; you are the branches. If you remain in me and I in you, you will bear much fruit; apart
from me you can do nothing.” (John 15:5). Jesus knew that people often learn best when they
are able to move from what is known (familiar) to what is unknown (unfamiliar). By using
metaphors Jesus showed that he was the master teacher by using comparisons and contrasts of
things that were familiar to his audience. He made the complex simple and easy to
understand. Buddha was another great master teacher by using metaphors: “Just as a candle
cannot burn without fire, men cannot live without a spiritual life” (Buddha). Metaphors can
also be found in quotes of notable people: “A good conscience is a continual Christmas”
(Benjamin Franklin), or “Conscience is a man’s compass” (Vincent Van Gogh).
3.3. Relationships oriented

Human beings are, by nature, social (Vygotsky, 1987). We need and depend upon
relationships with others in order to survive and develop. Interpersonal relationships are the
foundation and theme of human life, and most human behavior takes place in the context of
the individual's relationships with others. Psychologists believe that the human's omnipresent
relationship context strongly influences each individual's behavior and his or her development
over the life span (Reis, Collins, & Berscheid, 2000).
Clients seen in art therapy frequently complain of feeling disconnected and alienated
from themselves or other people. At other times, they may feel overwhelmed or persecuted by
them. For many art therapists, the origins of these difficulties reside in past relationship
problems (Edwards, 2014, p. 43).
Robbins (2000) indicated that “… In art therapy, we are constantly working to make
aesthetic expression a complement to self-expression in one’s relationship with others. In that
process, the art therapist works with an individual’s character defenses and slowly helps him
to digest emotionally the full impact of the symbolic communications so that there is a real
awareness of what is being said in symbolic form and of how the client can manifest that in
ongoing relationships with others” (p. 23).
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According to Robbins (2000), “In essence, the therapist creates a holding environment
in which empathy is the basis of communication. Empathic contact becomes a bipolar bridge
that respects the defenses while addressing the wish to be understood” (p. 27).
Jerome Frank, in his classic work (1973), has described the “essential features” shared
by all effective psychotherapies: (a) the helping relationship that offers caring and empathy
and mobilizes hope, (b) a special setting that provides shelter from ordinary demands, (c) an
optimistic philosophy of life and a rational explanation for the problems, (d) powerful
procedures that demonstrate the powers of the therapist, arouse the patient’s emotions, and
permit him or her to demonstrate mastery.
4. Functions of Art therapy
4.1. Art therapy as a therapeutic process

There are several significant interpretations of the ways art may be used in the
therapeutic process. Ulman (1975) points out that in the broadest interpretations art therapy is
the use of any visual materials “in some attempt to assist integration or reintegration of the
personality” (p. 3). The various forms art therapy seem to take may in large part emerge from
the setting in which it is practiced. For example, art in clinical settings has produced
psychoanalytic applications, while art in educational settings has produced an emphasis on the
integration of cognitive and emotional processes to enhance development, motivation,
behavior, and learning (Williams & Wood, 1977, p. 5).
Deny (1972) has encompassed an eclectic position into his art therapy techniques.
With an emphasis on the client’s needs, he suggests that art may be effective in a wide range
of behavioral processes, including “… catharsis, increase or decrease in effective
communication, self-disclosure, and changes in attitude and behavior” (p. 118). He further
elaborates on art therapy techniques under six headings: exploration, building rapport,
expression of inner feelings, self-perception, interpersonal relations, and the individual’s
place in his world. These categories, each describing a different focus, suggest one approach
to guiding the art therapy process (Williams & Wood, 1977, p. 6).
4.2. Art therapy as a developmental process

Art therapy uses the knowledge of a child’s developmental stages to assess the
psychological makeup and normative progression of the child or adult (Gerber & Lyons,
1980) in order to develop an art therapy treatment plan. It involves sensitivity to the child’
psychosocial developmental status and attempts to identify the conflicts and issues, cognitive,
emotional and behavioral that may be preventing progressive development (Gerber & Lyon,
1980; Lowenfeld, 1947).
Rubin (1978) calls the creative process a learning experience (p. 268). In art, even a
child may have what Maslow calls a “peak experience” (1959), or may feel a sense of
heightened awareness and aliveness, what Ulman calls “a momentary sample of living at its
best.” (1971, p. 93). Through art, a youngster may experience not only the momentary release
of tension through a discharge of surplus energy, but the release of unconflicted energy,
newly available for constructive use, through the sublimation and resolution of conflicts once
draining his resources. Through art, a process in which one is in touch with all levels of
consciousness (Kubie, 1958), and with external stimuli, one’s level of awareness may be
enlarged, expanded, deepened, and sharpened. “This openness to experience may itself be
experienced: first, as a mood; secondly, as understanding; and thirdly, as expression.”
(Kaelin, 1966, p. 8)
A child can, in art, develop autonomy and independence, taking responsibility for both
process and product. He can learn to choose, to make, to act, to revise decisions, to appraise
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and evaluate, and to learn from past experience. In art a child can experiment symbolically,
may try out in both process and product feelings and ideas which may eventually become
possible in reality. He can manipulate media which do not talk back, enabling him to
experience a kind of power and mastery at no risk. He can master tools and processes, and can
feel competent. He can learn to accept his regressive/aggressive symbolic self, and can come
to value his creative/productive self, leading to a deep feeling of self-worth. He can discover,
develop, and define his uniqueness, creating in and through his art a sense of himself as
special. He can experience the pleasure of an aesthetically fine product, the joy of sharing it
with a loved one, the pride in the affirmation of another (Rubin, 1978, p. 269).
Kagin and Lusebrink (1978, in Lusebrink, 1990, p. 92-95) and later Hinz and
Lusebrink (Hinz & Lusebrink, 2009) formulated a conceptual model of expression and
interaction with media on different levels constituting the Expressive Therapies Continuum
(ETC). This model consists of four levels organized in a developmental sequence of image
formation and information processing. The first three levels reflect the developmental
sequence and increasing abstraction in information processing in the following sequence:
kinesthetic/sensory level (K/S), perceptual/affective level (P/A), and cognitive/symbolic level
(C/Sy). The fourth level, the creative level (CR), can be present at any of the previous levels
and may involve synthesis of all the other levels.
 The kinesthetic/sensory level corresponds to sensorimotor stage of cognitive
development (Piaget, 1969) and focuses primarily on the preverbal experiences, the release of
energy and expression through bodily action and movement (kinesthetic), as well as tactile
and haptic, internal or external sensations experienced by interacting with art media (sensory).
Developmentally this is the way in which children process information: they physically
manipulate materials to form internal images of them (Lusebrink, 1991; Piaget, 1959;
Vygotsky, 1962). Besides that, the rhythm created by the motoric and affective aspects
accompanying the act of drawing produces a sense of relaxation and stability. Kinesthetic and
sensory information gathered from the manipulation of art materials forms the basis of many
experiences, and thus greatly influences the understanding of emotion and the development of
memory (Damasio, 1994; Lusebrink, 2004; Siegel & Hartzell, 2003).
 The perceptual/affective level represents the interaction between the perceptual
and affective aspects of expression and the influence of different media upon that interaction.
Individual perceptions of reality are neurologically based, culturally influenced, and different
from other individuals’ perceptions. In order to have fulfilling relationships it is helpful if
people understand the concept of representational diversity and are open to new perceptual
experiences (Hinz & Lusebrink, 2009, p. 10). The perceptual pole of this level focuses on the
form or structural qualities of the expression, such as defining boundaries, differentiating
forms, and striving to achieve an appropriate representation for an inner or external
experience. Media with high structural qualities (e.g., wood or mosaic) are more likely to
evoke an inner organization in the individual than fluid media (e.g., watercolor) where the
individual has to impose a structure upon the medium. Art therapy experiences on the
perceptual/affective level can be designed to broaden clients’ perspectives and increase their
ability to see another person’s point of view through a new visual language. In addition,
everyone should understand and have access to information about their emotional states.
Emotions are used in decision making, memory functioning, and motivating behavior
(Damasio, 1994; Ekman, 2003; Plutchik, 2003). The affective component of this level
modifies the form, and the form in turn gives a structure to affect. The innate striving for good
gestalts may be countered by emotional expression and distortion of the form created or
perceived. Extreme examples of this interaction can be seen in either in the distortion of form
in angry expressions or in the containment of anger in a geometrization of form. The use of
intense colors and fluid media, such as poster paint, facilitates the expression of affect.
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Identification of the forms facilitates the expression of affect and the internalization of
structure. The internalization and abstraction of perceptual and affective schemata lead to the
following C/Sy level. Experiences on the perceptual/affective level can help clients identify
emotions, facilitate discrimination among emotional states, and assist in the appropriate
expression of emotions (Hinz & Lusebrink, 2009, p. 11).
 The cognitive/symbolic level corresponds to adolescence and the development
of formal operational thought (Piaget, 1969). Because adolescents are able to think outside
their own experience, and their thoughts have achieved a new level of complexity, they are
able to use symbols to represent feelings, thoughts, and events (Hinz & Lusebrink, 2009, p.
12). This level encompasses conceptual and anticipatory operations with images and the
corresponding verbalizations describing these operations. The cognitive component of this
level focuses on analytical, sequential operations; logical thought; and problem solving.
Abstractions and concept representation through visual forms are part of cognitive operations.
Resistive and structured media, such as pencils or construction paper, enhance operations on
the cognitive level. Naming the product, verbalization of the procedure, and internalization of
verbal commands constitute part of the cognitive level. Input from the cognitive component of
the ETC provides reality feedback in all areas of information processing. The symbolic
component of this level focuses on intuitive concept formation, realization and actualization
of symbols, and the symbolic expression of meaning. The symbols formation per se may lead
to the sublimation of more basic drives into culturally acceptable expression, thus leading to
the next or creative level. Potentially, everyone can benefit from the ability to understand and
use symbolic thought. Symbols provide access to intuitive functions, and serve as reminders
that experiences are not entirely conscious and fully understood. Art therapy with the
symbolic component of the ETC can aid clients in accessing the wisdom of their bodies or the
wisdom of the world, neither of which speak in words. Symbol use can allow clients to
maintain a healthy sense of mystery in their lives (Hinz & Lusebrink, 2009, p. 12).
 The creative level of the ETC may exist at any or in all levels, and often serves
an integrative function. It emphasizes the synthesizing and self-actualizing forces of the ego
and self. Jung (1964) stated that all persons show a tendency to grow toward wholeness,
bringing to light their uniqueness and individuality, and for him, this tendency was best
displayed by the creation of a mandala. According to Johnson (1990), creative experiences
can destroy a “false self” developed in response to shame, and can reinforce an authentic
sense of self. The sublimation is an example of a creative act. The creative act culminates in
an affective experience of closure and a sense of unity between the medium and the message.
In all types of creative experiences, the artist feels intense joy, which May (1975) defined as
“the emotion that goes with heightened consciousness, the mood that accompanies the
experience of actualizing one’s own potentialities” (p. 45).
A well-functioning individual is able to process information on all levels and with all
components or functions of the ETC. However, most individuals seeking therapy would not
consider themselves functioning optimally, but rather as experiencing problems with living.
The ETC helps therapists conceptualize these problems in at least two ways. Problems with
living that can prompt individuals to seek psychotherapy occur when people are blocked from
receiving or processing information from one or more components of the ETC. Difficulties
also can arise when individuals demonstrate strong preferences to process information
exclusively with one component. When information processing strategies are limited by being
blocked or overused in a restricted manner, decision-making skills are impaired and life
choices often are too narrowly defined (Hinz & Lusebrink, 2009, p. 14).
The ETC can be used to assess clients’ preferred and blocked levels of information
processing and to prescribe desired therapeutic experiences. The structure of the ETC can
help creative arts therapists assess both their clients’ favored components and significant
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obstacles to optimal functioning. This assessment information is gathered through evaluating
media preferences and styles of interaction with the media, as well as graphic indicators and
expressive elements from final art products. Further, therapists can use information from the
ETC to guide clients through experiences designed to eliminate impediments to effectively
using any component, or to reducing overdependence causing rigid functioning. Clients’
social and occupational functioning can be improved by removing obstacles, and increasing
flexibility in the ways information is processed and decisions are made. (Hinz & Lusebrink,
2009, p. 15).
Questions posed to the client can be primarily directed at expression on different
levels of the ETC in the following manner (Lusebrink, 1990):
 “What are you doing?” “What do you want to do?” “Can you act it out?” are
directed to responses on the kinesthetic level.
 “What do you sense?” brings the focus of attention to sensation.
 “What do you see or perceive?” directs attention of the perceptual aspects of
the expression.
 “How do you feel?” focuses on affect.
 “How do different parts relate to each other?” “What are the necessary steps to
solve the problem?” and similar questions address cognitive operations.
 “What does it mean to you?” or “What associations do you have with it?” elicit
elaborations on the symbolic aspects of the expression.
It is best to avoid questions using why because they tend to lead to rationalizations.
5. The Use of Media in Art therapy

The manipulation and purposeful grasping of art therapy media can often be
experienced as a non-verbal language (Hass-Cohen, 2007). Naumburg believed that positive
therapeutic outcomes could be achieved solely through the use of pastels and poster paints
(Naumburg, 1966). Robbins and Sibley (1976) stressed the importance of offering an ample
assortment of media (p. 207). However, it is the purposeful manipulation of the art media and
the art production that play the therapeutic role in art therapy, not solely the art media per se.
For instance, in one study, creating collage images was associated with decreased negative
mood, but merely viewing and sorting pictures was not (Bell & Robbins, 2007). Drake et al.
(2011) compared writing and drawing (both with black pen) to ameliorate negative mood and
found significantly more positive effects for drawing than writing. Curl (2008) studied the
effects of drawing and collage, carried out with either a positive or negative mental
framework, and found that both art tasks, paired with a positive cognitive focus, reduced
stress.
5.1. More structured and less structured media

Art media exists on a continuum from most structured to least structured. At the most
structured end are media like graphite pencils and colored pencils. These are media with more
inherent structure are called resistive because they resist easy alteration. They are advocated
for control (Malchiodi, 1998), create precise lines, and promote a considered and thoughtful
experience. Other materials like collage, stamps, and pens or markers would also be
considered structured and controlled. Anxious individuals will often feel more comfortable
with structured media as this allows them to have a greater sense of safety and control during
the art-making experience. The most structured materials are usually provided at the
beginning of art therapy treatment to help clients feel comfortable with the process. Pencils
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and markers that are easy to draw with and allow for details might be appropriate options for
concrete tasks, such as creating picture of self-portrait, or a family doing something together.
Toward the less structured or more fluid media are materials like watercolor paints, oil
paint, chalk pastels, and clay. These media can be very expressive but are more difficult to
control. They tend to increase the emotional experience and expressiveness (Horowitz &
Eksten, 2009; Rubin, 2011). Paint or oil pastels might be more motivating for a directive that
involves something like representing how you are feeling, since they may help to deepen the
emotional experience and expression. Fluid media are also believed to access unconscious
processes, mediated on a preverbal level by the right hemisphere of the brain, and thus aid in
the integration of long-term memory (Morley & Duncan, 2007) and trauma recovery (Gantt &
Tinnin, 2009).
Many people also find watercolors and other fluid media to be relaxing and
encouraging of a more meditative experience. However, fluid media and the resulting
emotional vulnerability can be too overwhelming for certain individuals, such as those with
severe trauma history or psychosis. In working with ADHD children, painting or wet clay can
quickly become an out of control mess if the children have not yet developed enough self-
control, patience, and frustration tolerance.
5.2. Media that enhance the Expressive Therapies Continuum

Kagin and Lusebrink (1978) developed information about media variables and
incorporated it into the ETC framework. For example, according to Kagin and Lusebrink
(1978), materials on the kinesthetic/sensory level of the ETC can serve as mere facilitators of
action or sensation. Materials on the perceptual pole of the perceptual/affective level
emphasize form dimensions of the media experience. Experiences in which form arises from a
background, such as contrasting colored papers or drawing media, help contribute to a
perceptual experience. Fluid media, as was mentioned above, can evoke affect. The use of
watercolor paint on wet paper is a rapidly flowing activity that often induces an affective
experience. Symbolic experiences come from ambiguous forms, such as those produced by
sponge painting or blot painting. Ambiguous forms encourage organization into recognizable
symbols that can be imbued with personal meaning (Lusebrink, 1990). Materials that involve
precision, planning, and complicated thought processes evoke cognitive experiences. Pencils
for drawing involve precision, and planning is involved in the cutting and pasting required in
creating a collage.
Other elements to consider in providing art therapy are the size of paper that is used
and individual media preferences. Small paper provides a greater sense of containment
whereas large paper encourages freedom and expansiveness. Individual preferences for
different media should also be kept in the art therapist’s mind. Sensory preferences can be an
important aspect of personal preference, especially in children. Individuals with tactile
defensiveness may be very uncomfortable with clay, play dough, or finger painting.
Conclusion
Art therapy is a human service profession in which art materials, the creative process,
and a final art product are the vehicles for therapeutic interaction. Whichever art therapy
model is utilized, personal awareness and growth will take place as patients or clients interact
with art materials and learn something about themselves from the process of using these
materials purposely. Art therapy has several characteristics, including non-verbal
communication, metaphoric meaning and relationship orientation. These features, along with
Expressive Therapies Continuum levels, bring art therapy both therapeutic and developmental
functions.
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Effective therapeutic outcomes could be achieved through the appropriate use of art
media, which exist on a continuum from most structured to least structured. Art therapist must
consider the media being used according to clients’ or patients’ psychological characteristics,
individual preferences and their Expressive Therapies Continuum levels.
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Received: 20.05.2016.
Information about the author
Minh-Anh Nguyen – PhD. in Psychology, Fulbright Visiting Scholar, Drexel

University, Philadelphia, PA, USA; Head, Research Management & International
Cooperation Office, National College of Education in Ho Chi Minh City, Vietnam.
E-mail: minhanh0401@gmail.com
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Art Therapy – A Review of Methodology

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Art Therapy – A Review of Methodology

Keywords: art therapy, art education, symbolism, non-verbal communication, metaphor,

“Emotion, which is suffering, ceases to be

1. Definition of Art therapy

1.1. Art therapy

1.2. Art therapy vs. Art education

2. Two leading models of Art therapy

2.1. Art in therapy of Margaret Naumburg

2.2. Art as therapy of Edith Kramer

3. Characteristics of Art therapy

3.1. Non-verbal communication

3.2. Metaphor as therapeutic means

3.3. Relationships oriented

4. Functions of Art therapy

4.1. Art therapy as a therapeutic process

4.2. Art therapy as a developmental process

5. The Use of Media in Art therapy

5.1. More structured and less structured media

5.2. Media that enhance the Expressive Therapies Continuum

Information about the author

Minh-Anh Nguyen – PhD. in Psychology, Fulbright Visiting Scholar, Drexel

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